REPUBLIC OF THE PHILIPPINES )

) S.S

AFFIDAVIT TO USE THE SURNAME OF THE FATHER

I, REMEDIOS BENESISTO CARDAÑO, of legal age, Filipino, Married, and with

current address at #320 Sampaguita St. Brgy. Perez Sto.Niño Meycauayan City, Bulacan,
after having been duly sworn to in accordance with law, hereby depose and state that:

1. That I am the mother of BEA BENESISTO, who was born on November 02,
2014, at Malolos Provincial Hospital, Malolos Bulacan.

2. That me and my common law husband, EDDIE JIMENEZ were not married

3. That I want my daughter, BEA BENESISTO to use the surname of my husband,

JIMENEZ.

4. That I am executing this affidavit to inform the authorities concerned for all
legal intents and purposes it may serve.

AFFIANT BAYETH NAUGHT

IN WITNESS WHEREOF, I have here unto set my hand this 28th Day of October
2021, hereat Meycauayan City Bulacan.

REMEDIOS BENESISTO CARDAÑO

Affiant

SUBSCRIBE AND SWORN TO BEFORE ME, This 28th Day of October 2021, hereat
Meycauayan City Bulacan. Affiant exhibited to me his/her Government Identification
card with number ______________________ issued at _________________ on
__________________.

Doc No. _____

Page No. _____
Book No. _____
Series of 2021